Early Goal Directed Care of the Acute Ischaemic Stroke Patient: A Nursing Perspective

Authors

The
authors work in a 32-bed neurosciences ICU, a state-of-the-art facility located
at a level 1 trauma centre on the west coast of Florida.

As
neuroscience nurses we encounter a multitude of challenges in caring of the
acute stroke patients. Early goal directed treatment is the key to improving
patient’s longterm outcomes. Our goal as the bed-side practitioner, in
conjunction with the medical staff, is to minimise cerebral injury and preserve
penumbral tissue.

Acute
Ischaemic Stroke (AIS) is the third leading cause ofdeath in the United States and literature
cites the percentage of AIS to be upwards of 85%. In an ischaemic stroke,
injury occurs when a region of brain tissue has a reduced blood flow for a
period of time sufficient enough to cause ischaemic and infraction. The
infracted tissue which is unsalvageable, is known as umbra (infract core) and
the ischaemic tissue, which is hypoperfused, but not irreversibly damaged, is
known as penumbra. The timely restoration of blood flow to the penumbral tissue
is the ultimate goal of all the medical and nursing management.

In the
care of the stroke patient, the beside practitioner should allow the ABCs of
assessment to guide their treatment and monitor their medical exam.

Airway/Breathing

In
close frequent patient assessment , airway management must always remain a
priority. Intubation may be increase for a Glasgow Coma Scale (GCS) of 8 or
less. Frequent ABG’s are necessary to followPaO2 levels and CO2 levels, since these two values play a critical role
in the ischaemic brain. The more alert stroke patient may only require
supplemental oxygen to

Augment
O2 delivery to the penumbral tissue.

Circulation

Careful
monitoring of patient’s vital signs is crucial . These valuable data may be one
of the first signs of clinical neurological deterioration. AIS patients present
with acute hypertension that often improves over the first 24-48 hours of
symptom onset.

Management
of this hypertension can be labour intensive for the beside nurse. In a patient
who has received IV-Tpa, the literature guides us to keep their BP<185/100
to prevent a haemorrhagic transformation, but one must be sensitive to a
patient’s baseline BP parameters to prevent decreasing penumbral perfusion,
especially since this hypoperfused tissue loses its autoregulation abilities
and perfusion is directly linked to the patient’s Mean Arterial Pressure
(MAP).IV Labetolol , Hydralazine, or Cardene are often used to manage this
hypertension, secondary to their short-acting nature. When an ischaemic stroke
patient does not qualify for Tpa administration, the acute, often transient,
hypertension is often only treated when the BP is over 220/110. Literature
recommends lowering BP by 15%while closely monitoring patients for symptoms of
clinical deterioration. The guidelines suggest restarting patients home
antihypertensive regimen on the day 2 if they are neurologically stable.
Positioning the head of the bed flat to 15degrees can augment circulation to
the ischaemic penumbra.

This
improves blood flow through often stenotic vessels and helps to improve
collateral flow.

Temperature
Management

Maintaining
euthermia is important for the AIS patient. Fever is cited to dramatically
worsen cerebral ischaemia and worsen long term patient outcomes. Antipyretics,
such as acetaminophen are often standard practice, but frequently proved
ineffective in controlling fever in the brain injured patient. The beside
practitioner, in conjunction with medical staff, must rule out possible sources
of infection, while actively working to maintain euthermia or even mild
hypothermia. Goal temperatures of 35-37 degrees Celsius have been shon to be
neuroprotective in nature and can often been achieved through either surface
cooling or intravascular temperature management modalities. In our experience,
intravascular cooling has been the method of choice due to its speed, accuracy,
and ease of use, with noted reductions in patient shivering. Hyperthermia has
been shown to increase the release of neurotransmitters, increase oxygen free radical
production, increase the blood brain barrier breakdown, and increase damage to
penumbral tissue secondary to ischaemic depolarisation and cellular calcium
influx. Temperature management is a vital part of caring for the AIS patient.

Nutrition

In
patients with AIS, it is prudent to assess swallowing function prior to
initiating any PO intake. Early nutrition is important secondary to increased
energy demands, and maintenance or replacement of albumin levels, which
directly affect osmotic pressure, helping to keep fluid in the intravascular
space. Placement of a nasogastric or feeding tube should be initiated within
the first 24 hours of admission, followed by appropriate caloric assessment by
a hospital dietician. Tight blood glucose control is imperative to prevent
anaerobic metabolism and local cellular lactic acid production, which directly affects
penumbral tissue.

Mobility /DVT Prophylaxis

Patients
suffering from AIS are often immobile for the first several days of hospital
admission and are at an increased risk for DVT/PE formation. Patients often
receive SQ administration of Heparin or Lovenox, and also the application of
sequential compression devices.

Fluid Volume Status

Maintaining
euvolemia is essential to maintaining effective penumbral circulation with the
AIS patient. In our facility, we often account for insensible fluid loss by
calculating a patients hourly output and replacing that output the next hour
plus and extra 20ml of crystalloid solution. This diligent replacement of
insensible fluid loss prevents the collapse of the thin walled arterioles of
the ischaemic penumbra. Patients with extensive strokes with significant
cerebral oedema may also require intermittent Mannitol administration or
hypertonic saline (3% NS) administration to aid in the management of increased intracranial
pressure. Acute ischaemic strokes in the posterior fossa region often require
placement of an external ventricular device to help manage the symptoms of
hydrocephalus from fourth ventricle outflow obstruction.

Acute Anticoagulation

There
is conflicting information in the literature regarding the practice of
anticoagulation therapy. In the past, it was standard practice to place
patients with a history of atrial fibrillation or other highrisk conditions for
secondary clot formation on IV Heparin therapy. Studies have shown that these
older anti-coagulation practices put patient at a high risk for haemorrhagic
transformation of the original injury and that heparin therapy does not aid in
revascularisation of the initial injury site; it only decreases incidence of
new clot formation. Early administration of antiplatelet drugs, such as aspirin
and Plavix, has become the favoured approach in treating ischaemic strokes. If
heparin therapy is initiated, careful patient and lab monitoring are essential.
Hourly neurological assessments are essential to monitor for any clinical
decline. The bedside nurse must be wary of the possibility of a haemorrhagic
transformation. In the event this devastating event does occur, the Heparin
must be shut off immediately, the MD notified, a head CT should be performed
and the coagulopathy should be corrected to baseline.

Revascularisation Therapies

Revascularisation
is the key to long term functional outcomes. There are several options
available to AIS patients to reperfuse the occluded vessel, assuming they
present to the hospital in the predetermined time frame, from the onset of
stroke symptoms. If a patient presents within three hours of symptom onset and
they meet all the inclusion criteria, they may receive IV-tPA in attempt to
restore blood flow to the blocked artery. Literature states this drug may be
administered outside of the standard three-hour window, but its efficacy is
decreased dramatically. ER staff must be proactive and place several large-bore
IV’s, a Foley catheter, and a feeding tube before administering this
medication, because once the IV-tPA is administered, all invasive procedures
should be avoided for 24 hours secondary to the increased risk of bleeding. If
a patient presents within six hours of symptom onset, intra-arterial TPA
administration is an option coupled with other various cutting- edge
interventional revascularisation therapies.

Conclusion

Ultimately
the fate of the patient lies in the diligence of the bedside nurse and medical
staff. Aggressive treatment, including oxygenation status, airway protection,
blood pressure control, temperature management, frequent neurologic
assessments, intracranial pressure management, anticoagulation therapy and good
supportive nursing care make all the difference when it comes to salvation of
the penumbral tissue. Decreasing stroke size is key to limiting a patients’
lifelong disabilities, improving outcome, and ultimately, improving overall
quality of life.

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